Wider focus holds key to unlocking improvement in global injury care

Embargoed copy of the research paper available on request

Global health policymakers should focus on the way entire healthcare systems work together - improving one element does not always create better outcomes if the wider system is not ready.

Publishing their findings today (21 June) in BMJ Global Health, an international research team led by the University of Birmingham, Nottingham Trent University and Stellenbosch University reveals how well-intentioned changes to one part of a healthcare system can lead to worse patient outcomes.

In one of the first studies to capture the full complexity of a health system delivering injury care, researchers mapped how patients move through care, from seeking and reaching help, to receiving treatment, and remaining in care for recovery.

They found almost 1,000 interconnected factors that influence patient survival after injury in low- and middle-income countries (LMICs), which account for around 85% of injury-related deaths worldwide. However, health systems are highly complex and interconnected – improving one part can unintentionally create pressure elsewhere.

Researchers discovered that, among several possible interventions, enhancing trust in the healthcare system had the greatest impact on clinical outcomes. When trust is high more people seek care and outcomes can improve, but if too many people come in and services cannot cope, quality drops and trust can fall again.

Lead author, Justine Davies, Professor of Global Health Research at the University of Birmingham, said: “Our work clearly shows that improving care results in increased demand on the health system, but this must be matched by greater capacity and higher-quality services to prevent services becoming overwhelmed. Increased demand quickly can lead to delays, reduced quality of care, and declining trust, ultimately undermining the very improvements those changes were intended to achieve.”

The study analyses interactions which span multiple pathways of care and their interactions including: patient and community factors, such as beliefs, ability to pay, and trust; health service factors, including quality of care, staffing, and funding; and wider societal context, such as poverty, infrastructure, and policy.

Senior author Antuela Tako, Professor of Operations Research at Nottingham Business School, said: “Patient trust, perceptions of care quality, and people’s willingness to seek treatment were among the most influential factors shaping health outcomes. However, addressing these factors in isolation is not enough. For example, increasing trust can encourage more people to seek care earlier, improving recovery and reducing mortality and disability.”

The research calls for a fundamental shift in how health systems are understood and strengthened through multi-sector approaches, linking health policy with investments in workforce capacity, transport, education, communities, and economic development.

Kathryn Chu, Professor of Global Surgery at Stellenbosch University, said: “Conventional approaches are insufficient to deliver sustained improvement. Things can only be truly improved through a whole-system approach that consider wider social and economic factors and places patient trust, system design and equity at the centre of reform.”

The research involved researchers from the UK and South Africa – including University of Aberdeen, UK; Umeå University, Sweden; University of the Witwatersrand, South Africa; National Health Service (NHS), Grampian, UK; University of York, UK; Western Cape Government, South Africa; University of Cape Town, South Africa; and South African Medical Research Council.

The study was supported by a prestigious two-month residential team fellowship awarded by the Stellenbosch Institute of Advanced Studies (STIAS) to Professor Justine Davies, Professor Kathryn Chu, Dr Lucia D’Ambruoso (University of Aberdeen), Professor Laura Bojke (York University) and Professor Antuela Tako.

ENDS

For more information, please contact:

• Tony Moran, International Communications Manager  t.moran@bham.ac.uk or +44 (0)7827 832312
• Helen Breese, PR and Research Communications Manager, helen.breese@ntu.ac.uk or +44 (0)115 848 8751

‘A systems approach to understand injury care in LMICs using causal loop diagrams’ - Justine I. Davies^, Kathryn Chu, Lucia D’Ambruoso, Laura Bojke, Rene English, Heike Geduld, Sa’Ad Lahri, Hassan Mahomed, Richard Matzopoulos, and Antuela A. Tako is published in BMJ Global Health.

Notes for editors

• The University of Birmingham is ranked amongst the world’s top 100 institutions. Its work brings people from across the world to Birmingham, including researchers, teachers and more than 40,000 students from over 150 countries.
• England’s first civic university, the University of Birmingham is proud to be rooted in of one of the most dynamic and diverse cities in the country. A member of the Russell Group and a founding member of the Universitas 21 global network of research universities, the University of Birmingham has been changing the way the world works for more than a century.

About Nottingham Business School at Nottingham Trent University

• Nottingham Business School (NBS) at Nottingham Trent University (NTU) is a leader in experiential learning and personalisation of business, management and economics education and research - combining academic excellence with positive impact on people, business and society.  NBS has an unrivalled level of engagement with business, public and voluntary organisations. With more than 8,500 students, NBS is also one of UK’s largest business schools.
• NBS is part of the 1% of business schools worldwide to hold the Triple Crown of accreditation from EQUIS, AMBA and AACSB. It is also accredited by Small Business Charter, providing support and development for SMEs, and is a PRME Champion - held up as an exemplar and beacon by the United Nations Principles of Responsible Management Education (PRME).
• In The Guardian University Guide 2026, all NBS subjects were ranked in the UK Top 20. Areas covering Accounting and Finance, Business and Management, Economics and Marketing and PR were all recognised for excellence in teaching, high student satisfaction and strong graduate career prospects.

About Nottingham Trent University

• Nottingham Trent University (NTU) has been named UK ‘University of the Year’ five times in six years, (Times Higher Education Awards 2017, The Guardian University Awards 2019, The Times and Sunday Times 2018 and 2023, Whatuni Student Choice Awards 2023) and is consistently one of the top performing modern universities in the UK. 
• Students have voted us the best university in the UK and 1st in the UK for student employability (Uni Compare 2025). 
• NTU is 4th in the UK for number of undergraduate students (HESA 2023-24) with over 36,000 students and more than 4,000 staff located across six campuses. It has an international student population of 6,000 and an NTU community representing over 160 countries. 
• NTU owns two Queen’s Anniversary Prizes for outstanding achievements in research (2015, 2021). The first recognises NTU’s research on the safety and security of global citizens. The second was awarded for research in science, engineering, arts and humanities to investigate and restore cultural objects, buildings and heritage. The Research Excellence Framework (2021) classed 83% of NTU’s research activity as either world-leading or internationally excellent. 
• NTU was awarded GOLD in the national 2023 Teaching Excellence Framework (TEF) assessment.
• NTU is a top 10 for sport (British Universities and Colleges Sport league table 2025) and was named as Sports University of the Year (Daily Mail University Guide 2025). It has also been ranked as 25th in the UK by the Guardian University Guide 2026.
• NTU is a holder of the University Mental Health Charter recognising the commitment an institution has shown towards continuous improvement in the area of mental health and wellbeing.
• NTU is the most environmentally sustainable university in the UK and second in the world (UI Green Metric University World Rankings, 2024).